British Journal of Psychiatry (1995), 167, 220—227 Episodes of Care for First-Ever Psychiatric Patients A Long-Term Case-Register Evaluation in a Mainly Urban Area MICHELE TANSELLA, ROCCO MICCIOLO, ANNIBALE BIGGERI,GIULIA BISOFFIand MATTEO BALESTRIERI Background.Psychiatriccase registers(PCRs)are particularlyuseful for studyingpatterns of care over time. Methods of ‘¿ survival analysis' have rarely been used for assessingsuch data. Method. A longitudinal study was conducted over 10 years (1 January 1982 to 31 December 1991) on 1423 first-ever psychiatricpatients, using the PCR of South Verona, Italy. The product-limitmethod,the log-ranktest, the Coxregressionmodelandthe Poissonregression analysis were used to analyse episodes of care and relapses. Results.The durationof the episodesof careincreasedconsistentlyfromthe firstto the fifth episode. The probability of opening a new episode of care after the first one increased consistently from the second to the sixth episode. The only variable significantly associated with the length of the first episode of care was diagnosis (highest probability of having longer episodes for schizophrenic patients), while the length of the breaks following the first episode of care was associated with diagnosis, sex and occupational status (highest probability of opening a second episode of care for schizophrenic subjects and those with alcohol and personality disorders, for males, and for unemployed patients). The probability of opening a new episode of care decreased with time since last contact and increased with number of previous contacts. Conclusions.The communitypsychiatricservicein SouthVerona isfulfillingits originalaim, that is, to give priority to the continuity of care for patients with chronic and severe mental illnesses. Survival analyses proved to be useful methods for assessing episodes of care. During the past few decades there has been a trend away from psychiatric hospitals towards a variety of locally based forms of community care for psychiatric patients, including people with serious mental health problems (Tansella, 1989; Marks & Scott, 1990). Current experience shows that it can be difficult to integrate hospital and community treatment and rehabilitation, to make the money follow the patients from old, large institutions to where they now live, to extend multidisciplinary professional and service-user involvement in manage ment, to ensure planning for the future and con tinuing training, and finally to encourage high standards of care and quality improvement (Rosen, 1992). As far as evaluation and research are concerned, since patients treated in areas where a community-based system of care is operating receive care from many facilities and institutions, sometimes overlapping during the same episode of illness, it is difficult to monitor and evaluate their patterns of care. Psychiatric case registers (PCRs) are parti cularly useful research tools in this respect. Service data provided by a PCR may be aggregated in several ways. Potentially useful methods of aggregation include aggregation by unit of time (e.g. mental health visits or admissions per year), by specific source of services or type of setting (e.g. visits to a community mental health centre), by type of care provided (e.g. visits made by psychiatrists), by illness episode (e.g. contacts with psychiatric facilities during an acute episode of schizophrenia), and by episodes of care (e.g. contacts made with a sequence of services involved in the diagnosis and treatment of a mental health problem) (George, 1989). The distinction between an illness episode (events in the time between the onset of recurrence of mental health problems and the resolution or remission of those problems) and an episode of care is important: the former is based on the mental health status of the individual and the latter on patterns of service use (George, 1989). In research into mental health services, the evaluation of episodes of care appear more useful than that of episodes of illness. This paper presents the results of a longitudinal study conducted over 10 years on episodes of care of first-ever psychiatric patients, using the South Verona PCR. In South Verona, psyc.@iatriccare was completely reorganised in 1978 according to the provisions of the Italian psychiatric reform. This reform stopped all admissions to mental hospitals and prescribed the setting up of integrated, community based psychiatric services to provide continuous and comprehensive care (including in-patient care, both voluntary and compulsory, in general-hospital psychiatric wards) to all patients living in defined geographical areas. 220